This document presents a case of spinal tuberculosis. It describes a 45-year-old female patient who presented with severe back pain of one week duration. Examination found tenderness in the lumbar spine and limited straight leg raise. Imaging including x-ray and MRI confirmed the diagnosis of spinal tuberculosis affecting L1 and L2. The document then provides details on the pathogenesis, clinical presentation, diagnosis, imaging features, complications and management of spinal tuberculosis.

1. Spinal Tuberculosis
Dr. Monsif Iqbal
Department of Surgery
POF Hospital, Wah Cantt

2. CASE PRESENTATION

3. Patient Profile
• Name : Rukhsana
• Age : 45 years
• Sex : Female
• Address : Wah Cantt
• D.O.A : 26/06/2011
• M.O.A : OPD

4. • Presenting Complaints
– Severe Backacke 5-7 days
• History of present illness

5. Past History
• h/o Cholecystectomy 01 month back
• Diagnosed as a case of HCV 01 month back

6. Drug HISTORY
• No histroy of any drug intake

7. PHYSICAL EXAMINATION
1. GPE:
A middle aged lady, lying in bed
His vitals are;
– Pulse: 85/min
– B.P: 130/80 mm of Hg
– Oxygen Sat: 96%
– Temp: Afebrile
Rest of GPE unremarkable.

8. NEUROLOGICAL EXAMINATION
• Tenderness in the lumbar spine (L1, L2)
• SLR
– Right 60 degress
– Left 70 degrees
• Sensory system intact
• Motor system intact
• Reflexes normal
• Plantars downgoing

9. Rest of the systemic examination
• Abdomen
– Cholecystectomy scar
• Chest
– NAD

10. Investigations on the day of admission
• Blood CP
• ESR
• LFTs
• X-ray Lumbo-sacral Spine

13. X-Ray Chest (PA view)

15. T1 weighted image

16. T2 weighted image

17. T1 weighted Slide

19. T2 weighted Slide

21. • So clinically the diagnosis of Spinal
Tuberculosis was made

22. Spinal Tuberculosis

23. Introduction
• According to WHO(2010), about one third of the
world’s population is infected by Mycobacterium TB,
and 9 million individuals develop TB each year
• One third of total TB population is in South-East Asia.
• Three percent are suffering from skeletal TB.
• Vertebral TB is the most common form of skeletal TB
and accounts for 50% of all cases of skeletal TB.

24. • The mortality rate is 27/100,000 of the population.
• Neurological complications are the most crippling
complications of spinal TB
(Incidence : 10 to 43%).

25. Spinal Tuberculosis

26. Pathology of Spinal TB
• Spinal tuberculosis is usually a secondary infection
from a primary site in the lung or genitourinary system.
• Spread to the spine is hematogenous in most
instances.
• Delayed hypersensitivity immune reaction.
• The basic lesion is a combination of osteomyelitis and
arthritis…. Affects the anterior part of vertebra…

27. • Kyphosis
• Paravertebral Abscess

28. Clinical Presentation
• Presentation depends on :
– Stage of disease,
– Site
– Presence of complications such as neurologic deficits, abscesses, or
sinus tracts.
• Average duration of symptoms at the time of diagnosis is 3 – 4
months.
• Back pain is the earliest & most common symptom.
• Constitutional symptoms.
• Neurologic symptoms (50 % of cases).

29. • Cervical spine Tuberculosis
• Spinal TB in HIV patients

30. Spinal Tuberculosis Diagnosis
• Lab Studies
– Mantoux / Tuberculin skin test ( purified protein derivative
{PPD})
– ESR
– ELISA : for antibody to mycobacterial antigen-6 , sensitivity of 60
– 80%.
– PCR : sensitivity of 40% only.
– Brucella complement fixation test (useful in endemic areas as
brucella can clinically mimic tuberculosis).

31. – IFN – Release assays (IGRAs)
Recently, two in vitro assays that measure T-
cell release of IFN in response to stimulation
with the highly specific tuberculosis antigens
ESAT- 6 & CFP-10 have become commercially
available.
• Microbiology studies
– Ziehl-Neelsen staining
– Cultures positive in 50 % of the cases only

32. Spinal Tuberculosis Diagnosis
• Radiological Diagnosis
– Plain Radiograph
– CT Scan
– MRI Spine

33. Plain Radiograph
• Typical tubercular spondylitic features in long standing paraspinal
abscesses
– produce concave erosions around the anterior margins of the
vertebral bodies producing a scalloped appearance called the
Aneurysmal phenomenon.
– fusiform paraspinal soft tissue shadow with calcification in few .
• Skip lesions as involvement of non contiguous vertebrae (7 – 10 %
cases).
• DEFORMITIES:
1. Anterior wedging
2. Gibbous deformity.
3. Vertebra plana = single collapsed vertebra .

35. wedge collapse of L1 and L2 vertebral bodies

36. X-ray of the spine in a child showing complete
destruction of D12 and L1 vertebral bodies leaving only
the pedicles.

37. CT Scanning
• CT scanning provides much better bony detail of irregular lytic
lesions, sclerosis, disk collapse, and disruption of bone
circumference.
• Low-contrast resolution provides a better assessment of soft tissue,
particularly in epidural and paraspinal areas.
• It detects early lesions and is more effective for defining the shape
and calcification of soft tissue abscesses.
• In contrast to pyogenic disease, calcification is common in
tuberculous lesions.

38. MRI Spine
• MRI is the modality of choice as delineates leptomeningeal
disease better, direct evaluation of intramedullary lesions,
associated osseous signal change and epidural abscesses.
• Typical (spondylo-discitis) and atypical (spondylitis without
discitis) types.
• Differentiate tuberculous spondylitis from pyogenic
spondylitis
• most effective for demonstrating neural compression

40. Patterns of Vertebral Involvement

45. Deformities in Spinal Tuberculosis
• Kyphotic deformity (more common in thoracic spine) occurs
as a consequence of collapse in the anterior spine
• Knuckle Kyphosis : forward wedging of one or two VB causing
small kyphos
• Angular Kyphosis : wedge collapse of 3 or
more VB

47. Differential Diagnosis
• The differential diagnosis of the tuberculous spine
includes:
1. SPINAL INFECTIONS- pyogenic, brucella & fungal.
2.NEOPLASTIC commonly lymphoma/ metastasis
3.DEGENERATIVE
• No pathognomonic imaging signs allow tuberculosis to
be readily distinguished from other conditions. Biopsy
is definitive.

53. Complications of Spinal Tuberculosis
• Paraplegia
• Cold abscess
• Spinal deformity
• Sinuses
• Secondary infection
• Amyloid disease
• Fatality

54. What is Middle path regime?
• Rest in bed
• Chemotherapy
• X-ray & ESR once in 3 months
• MRI/ CT at 6 months interval for 2 years
• Gradual mobilization is encouraged in absence of neural deficits
with spinal braces & back extension exercises at 3 – 9 weeks.
• Abscesses – aspirate when near surface & instil 1gm Streptomycin
+/- INH in solution

55. • Sinus heals 6-12 weeks after treatment.
• Neural complications if showing progressive recovery on ATT
b/w 3-4 weeks :- surgery unnecessary
• Excisional surgery for posterior spinal disease associated with
abscess / sinus formation +/- neural involvement.
• Operative debridement–if no arrest after 3-6 months of ATT /
with recurrence of disease .
• Post op spinal brace→18 months-2 years

56. All first-line anti-tuberculous drug names have a standard
three-letter and a single-letter abbreviation:
• Ethambutol is EMB or E,
• isoniazid is INH or H,
• Pyrazinamide is PZA or Z,
• Rifampicin is RMP or R,
• Streptomycin is STM or S.

57. Surgical Indications
• No sign of neurological recovery after trial of 3-4 weeks therapy
• Neurological complications develop during conservative treatment
• Neuro deficit becoming worse on drugs & bed rest
• Recurrence of neurological complication
• Prevertebral cervical abscess with difficulty in deglutition &
respiration
• Advanced cases- Sphincter involvement, flaccid paralysis or severe
flexor spasms

60. THANKS